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Form 391 C - Designation Of An Authorized Representative Form - Highmark Blue Shield - Pennsylvania Page 2

Description of scope of representative's authority:

Represent member's interest in First Level Review

Represent member's interest in Second Level Review

Represent member's interest in all possible appeals

Other (

): _____________________________________________________________________

specify

__________________________________________________________________________________

Unless otherwise revoked, this authorization will expire on the following date, event, or circumstance:

(Insert date, event, or circumstance---if no date, event or circumstance is included, this Authorization

will expire one year after date of member signature)

Expiration Date: ____________________________

I understand that I have the right to revoke this designation at any time. Such revocation shall only become

effective upon receipt by Highmark, Inc. of notice of my revocation.

Member's Signature _________________________________________

Date _____/_____/________

Address: _________________________________________________

_________________________________________________

You are entitled to a copy of this authorization after you sign it.

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Form 391 C - Designation Of An Authorized Representative Form - Highmark Blue Shield - Pennsylvania Page 2